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Professional Affairs Office - Faculty of Medicine, University of Ottawa > Policies & Procedures > Confidential Disclosure of Conflict of Interest Form

Confidential Disclosure of Conflict of Interest Form

The University of Ottawa’s Faculty of Medicine requires that all faculty members and staff complete this Disclosure of Conflict of Interest form annually.  The 2010 Faculty of Medicine’s policy on “Interactions between the Faculty of Medicine and the Pharmaceutical, Biotechnology, Medical Device, and Hospital and Research Equipment and Supplies Industries”, Section 33 states:

On an annual basis, faculty members and staff will disclose, in writing, relationships with Industry to the Faculty of Medicine's Office of Professional Affairs.  Disclosures will be reviewed and if a significant unmanaged conflict of interest is identified, then the disclosure will be forwarded to Department heads or supervisors. The written disclosure must specify nature of the relationship with Industry, the work performed, and total amount and type of compensation or other benefit received.   Similarly, faculty members and staff will verify annually that their reporting was accurate and complete.  Management of unresolved conflicts of interest will be done in collaboration between the faculty member, the Office of Professional Affairs' Conflict of Interest Resolution Committee, the Department head and/or supervisor.

This form acts as a document that will be reviewed by the Faculty's Office of Professional Affairs and if warranted, will be reviewed with the Faculty member's Department/Divisional Chief.

For the purposes of this disclosure, Conflict of Interest (COI) is defined as:

Conflict of Interest (COI) may be actual, potential or perceived.  A conflict of interest occurs when an individual has a significant financial, professional or other personal consideration with Industry that may compromise, or have the potential to compromise or the appearance of compromising, their professional judgment or integrity in clinical responsibilities, teaching, conducting or reporting research, or performing other obligations.

Faculty Disclosure of Conflict of Interest

 * Indicates a required field

Given Name and Surname: *
Department: *
Division: *
Telephone No.: * - - ext.
Email Address: *
 
* Please select one of the following three options:
I do not have any affiliation (financial or otherwise) with a pharmaceutical, biotechnology, medical device, hospital or research equipment/supply industry that could be perceived as a direct/indirect conflict of interest as defined in policy Interactions Between the Faculty of Medicine and the Pharmaceutical, Biotechnology, Medical Device, and Hospital and Research Equipment and Supply Industries. 
I have/had an affiliation (financial or otherwise) with a pharmaceutical, biotechnology, medical device, hospital or research equipment/supply industry that could be perceived as a direct/indirect conflict of interest as defined in policy Interactions Between the Faculty of Medicine and the Pharmaceutical, Biotechnology, Medical Device, and Hospital and Research Equipment and Supply Industries. (Please complete the section below indicating the commercial organization(s) with which you have/had affiliations, and briefly explain the relationship you have with the organization.

Form Location

*

Please specify Institution

 
  Company/Organization Amount/yr Details
A. I am a member of an Advisory Board (or equivalent) of a commercial organization.

If you are a member of more than one Advisory Board of a commercial organization, Click here!

I am also a member of another Advisory Board (or equivalent) of a commercial organization







































 
B. I am a member of a Speaker's Bureau

If you are a member of another Speaker's Bureau, Click here!

I am also a member of another Speaker's Bureau







































 
C. I have received payment(s) or honorarium (a) from a commercial organization (ie. For speaking, consultation, participation in meetings)

If you have also received payment(s) or honorarium (a) from another commercial organization (ie. For speaking, consultation, participation in meetings) Click here!

I have also received payment(s) or honorarium (a) from another commercial organization (ie. For speaking, consultation, participation in meetings)







































 
D. I have received a grant(s) from a commercial organization

If you have also received a grant(s) from another commercial organization Click here!

I have also received a grant(s) from another commercial organization







































 
E. I hold a patent for a product marketed by a commercial organization

If you also hold a patent for a product marketed by another commercial organization Click here!

I also hold a patent for a product marketed by another commercial organization







































 
F. I hold investments in pharmaceutical, biotechnology, medical device, hospital or research equipment/supply industry

If you also hold other investments in pharmaceutical, biotechnology, medical device, hospital or research equipment/supply industry Click here!

I also hold other investments in pharmaceutical, biotechnology, medical device, hospital or research equipment/supply industry







































 
G. I am currently participating in or have participated in an industry sponsored clinical trial within the last two years

If you are also participating in or have participated in another industry sponsored clinical trial within the last two years Click here!

I am also participating in or have participated in another industry sponsored clinical trial within the last two years







































 
H. I have ownership individually or jointly in a company outside the University of Ottawa.

If you have ownership individually or jointly in anoter company outside the University of Ottawa, Click here!

I have ownership individually or jointly in another company outside the University of Ottawa.







































Certification

* I certify that the information that I have provided is true and that all of my significant relationships with industry have been disclosed. I understand that this disclosure must be updated on a yearly basis.